Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention

  • Date: Nov 03 2015
  • Policy Number: 20152

Key Words: Abortion, Access To Health Care, Reproductive And Sexual Health, Womens Health

Abstract

APHA policy has long held that access to the full range of reproductive health services, including abortion, is a fundamental right. International covenants recognize individuals’ human rights to decide whether, when, and how many children to have and to have the information and means to do so, free of coercion, discrimination, and violence. The reproductive justice framework calls for recognition of and redress for compounded economic, cultural, and structural disparities linked to race, gender, or class. Restrictions on funding and coverage for legal abortions from public and private sources have accelerated in the United States since 2010, with new laws intended to drive out or criminalize safe abortion services. These restrictions deny, delay, and impede access to abortion services, increasing women’s risk of injury or death; they also may coerce women to carry unintended pregnancies to term, elevating their risk of poverty and violating their human rights and rights as citizens. A public health strategy to achieve health in all policies, economic equality, social justice, and human rights should protect and advance women’s access to abortions and reproductive justice.

Relationship to Existing APHA Policy Statements

While consistent with existing APHA policies, this policy statement identifies the proliferation, since 2010, of measures that restrict access to abortions as major exacerbations of social, economic, and health inequalities requiring concerted public health intervention. Existing APHA policies establish that access to the full range of sexual and reproductive health care services, including abortion, is vital to public health and a basic human right and document limitations in funding, coverage, and access in selected state and federal laws and court decisions through 2010. They recognize voluntary male sterilization as part of the full range of reproductive health care and note the importance of informed consent and other safeguards regarding sterilization. These earlier policies include important analyses and detail and should remain in place. The most recent include the following:

  • APHA Policy Statement 200313: Preserving Access to Reproductive Health Care in Medicaid Managed Care. State Medicaid agencies and agencies regulating private insurance should allow contracts only with providers that offer comprehensive information and the full range of reproductive services.
  • APHA Policy Statement 200314: Support for Sexual and Reproductive Health and Rights in the United States and Abroad. This policy supports access to emergency contraception.
  • APHA Policy Statement 20083: Need for State Legislation Protecting and Enhancing Women’s Ability to Obtain Safe, Legal Abortion Services Without Delay or Government Interference. APHA urges educating state legislatures and elected and appointed officials as to the importance of opposing laws that restrict access to abortion services, provide the fetus with the legal status of a person, or define human life as beginning at the moment of fertilization or conception or legalize compelled childbirth. This policy also clarifies the importance of improving access to safe abortion services, protecting women’s full rights to reproductive autonomy and privacy in medical decision making, and calling on the public health community to work locally and with states to ensure access to safe, legal abortion.
  • APHA Policy Statement 20103: Protecting Abortion Coverage in Health Reform. APHA considers the availability of safe, legal, and affordable abortion care essential for safeguarding maternal health, reducing maternal mortality and morbidity, and enabling healthy spacing of pregnancies.
  • APHA Policy Statement 20112: Provision of Abortion Care by Advanced Practice Nurses and Physician Assistants.
  • APHA Policy Statement 201113: Call to Action to Reduce Global Maternal, Neonatal, and Child Morbidity and Mortality. Access to safe abortion prevents death and disability among women due to pregnancy-related causes and reduces child mortality.

Other important older policies include:

  • APHA Policy Statement 7841: International Population and Family Planning. This policy urges Congress to include in development assistance legislation specific recognition of the basic human right to decide freely and responsibly the number and spacing of one’s own children and the means of implementing this right to assist in providing a full range of services, including reversible methods delivered where appropriate by paramedical and community personnel, voluntary sterilization based on informed consent, and medically safe abortion for countries that request such help. Thus, the Helms Amendment prohibiting use of US funds for abortion should be repealed.
  • APHA Policy Statement 7704: Access to Comprehensive Fertility Related Services. APHA urges that, in instances in which abortion or sterilization is a method of choice, services be made available in concurrence with standards of informed consent adopted by APHA, through the local providers from which a person receives other health care. Also, hospitals, especially those that provide services to individuals whose health care is supported directly through government programs or indirectly through tax exemptions, should assist in providing such services, retain staff willing to perform the services, and provide referrals for nonhospital providers of the services.

Problem Statement

APHA policy has long recognized access to the full range of reproductive and sexual health care services as a fundamental right essential for women’s lives, for population health, and for advancing income equality, women’s rights, and women’s individual freedom.[1–7] These services include abortion, sex education, contraception, and health care before, during, and after a pregnancy; the well-established public health framework of primary, secondary, and tertiary prevention is used to address unintended pregnancy, with abortion included as secondary and tertiary prevention.[8]

International covenants recognize individuals’ human rights to decide whether, when, and how many children to have and to have the information and means to do this, free of coercion, discrimination, and violence. The reproductive justice framework recognizes that realizing these individual rights is linked to community conditions that exceed matters of individual choice and access; it calls for redress for economic, cultural, and structural disparities resulting from intersecting aspects of identity including race, gender, and class.[9,10] Human rights bodies increasingly find that “denying or obstructing a woman’s access to abortion contests women’s right to personal bodily autonomy [and] constitutes cruel, inhuman, or degrading treatment” and that states can be held accountable for denial of these reproductive autonomy rights.[11] The US Supreme Court recognized the legal right to obtain contraception in 1965 (Griswold v. Connecticut) and the right to an abortion in 1973 (Roe v. Wade).

Local, state, and national laws and regulations, court challenges, and media campaigns that obstruct patients’ access to abortions are accelerating in number and severity.[12] Since 2010, state legislatures in 36 states have enacted 205 restrictions on access to abortion care, leading to sharp increases in inequality in unintended pregnancies, births, and abortions in the United States. by race/ethnicity, income, and location; lower funding for women’s and children’s health services and worse health outcomes in states where anti-abortion campaigns have prevailed; and economic costs associated with exacerbated inequality.

These actions (1) restrict funding and coverage for abortions through both private and public sources, including through implementation of the Affordable Care Act at the state level, building on the Helms Amendment, which restricts US federal funds for abortions internationally, and the Hyde Amendment, which prohibits federal funding for abortions in the United States, primarily through Medicaid; (2) obstruct patients’ access to services; and (3) obstruct providers’ ability to practice. Collectively, these restrictions drive out or criminalize safe abortion services, forcing women to seek unsafe abortions at greatly elevated risk of injury or death[12] or coercing them to carry unintended pregnancies to term, elevating their risk of poverty[13] and denying them agency and full citizenship. Restrictions in public funding have concentrated the most severe and negative consequences among underserved and vulnerable populations with limited political power, namely low-income women and women of color.

Burdensome limits on patients’ access to care stigmatize abortion by treating it differently from other medical procedures, including by segregating the kinds of medical locations and providers of abortions.

A public health strategy to achieve health in all policies, economic equality, social justice, and human rights should protect and advance women’s right to access to abortions and advance reproductive justice by (1) demanding public funding for abortions through reversing the Hyde and Helms amendments; (2) calling for reversals of all policies restricting access to abortions as a result of their negative public health consequences; (3) asserting that severe barriers to access to abortions violate women’s rights to bodily autonomy, equity, and privacy and constitute cruel, inhuman, or degrading treatment; (4) reversing stigma associated with abortion care services and creating solidarity with and respect and empathy for women who receive abortions; and (5) asserting support for the conscientious provision of abortions, with health care clinicians framing abortion care as an extension of their requirement to place patients’ needs as the highest priority in providing treatment.

Restrictions on funding and coverage: The Helms Amendment, adopted by the US Congress as part of the Foreign Assistance Act in 1973, prohibits the use of US foreign assistance funds for “the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion.”[14] This provision has been applied as a complete ban on all abortion-related services and information, regardless of legality at the country level and without exceptions for rape or incest or when a woman’s life is endangered as a result of the pregnancy.

The amendment applies to recipient country governments, US and non-US nongovernmental organizations, and multilateral organizations such as the United Nations Population Fund. It amends the Foreign Assistance Act of 1961, is a permanent statute, and is referenced annually in appropriations legislation.

Access to safe abortion is a key factor in preventing deaths and disability among women due to pregnancy-related causes.[7] Each year, an estimated 22 million women and girls have an unsafe abortion, almost all in the developing world. As a result, 47,000 lose their lives and millions more suffer serious injury.[15] The economic and social costs of unsafe, delayed, or illegal abortions include maternal mortality, long-term complications from damage to reproductive organs, pelvic inflammatory disease, and secondary infertility, as well as potential harm to a woman’s existing children.[2]

Countries’ health systems incur huge costs in managing these preventable injuries, and their economies suffer from diminished economic participation. The World Health Organization asserts that safe abortion services should be available and accessible to the fullest extent of the law for all women, regardless of geography, ability to pay, age, gender, race, and ethnicity.[16]

Several developing countries have liberalized their abortion laws in the past decade to address the problem of unsafe abortion and to promote women’s human rights. However, the United States, as the largest financial supporter of family planning and reproductive health programs internationally, continues to resist these changes. Even in countries where abortion is legal, women and girls incur preventable deaths and injuries because they are denied access to information and safe abortion care in US-funded clinics and facilities. By limiting the availability of safe abortion services, the Helms Amendment imposes barriers on access to basic reproductive health care, thereby violating women’s fundamental human rights.[17]

The Mexico City Policy, also known as the Global Gag Rule, also negatively affected women’s ability to control their fertility.[18] First instituted by President Reagan in 1984, this rule prohibited foreign organizations receiving international family planning assistance from using private, non-US funds for any abortion-related activities, including service provision, referral and counseling, and discussion or advocacy related to abortion. Countries with proportionately higher levels of foreign assistance from the United States for family planning/reproductive health experienced more abortions after introduction of the Mexico City Policy,[19] probably because of lost funding for their family planning programs. The Mexico City Policy was rescinded by President Clinton on January 22, 1993; restored by President George W. Bush on January 22, 2001; and rescinded again by President Obama on January 23, 2009.

The Hyde Amendment, first enacted in 1976, prohibits the spending of federal funds for abortions in domestic US programs. The rule is not a permanent law; however, it is attached annually to congressional appropriations bills and has been approved by Congress every year since 1976.

Medicaid, a federally authorized health care program that is jointly funded and administered by the federal and state governments and covers low-income US residents, is the primary target of the Hyde restrictions.[2]

States can use their own funds to provide abortion coverage to Medicaid beneficiaries. Only four do so voluntarily, at their own initiative (Hawaii, Maryland, New York, and Washington); 13 others do so under a court order. Thirty-three states and the District of Columbia do not cover abortions through Medicaid. About 13% of all abortions in the United States are paid for with public funds (virtually all from state governments).[20]

The ban has been extended via other legislation to cover the Federal Employees Health Benefit Program, active duty and veteran women in the military, federal prison inmates, Peace Corps volunteers, and American Indian and Alaska Native women who obtain health care from the Indian Health Service.

The Hyde Amendment identifies exceptions, that is, circumstances in which federal funds can be used to pay for an abortion. These are pregnancies resulting from rape or incest or that pose a threat to the mother’s life. Appropriations legislation has recently extended these exceptions to Peace Corps volunteers and military women. Some state policies limit the availability of coverage for abortion services in private or Medicaid plans to these same exceptions or are even more limited, for example allowing abortions only in the case of life endangerment.[21]

However, “exceptions” present additional complications. Fragmented rules and systems make it difficult for women, health care providers, and payors to know whether or not their state, or their particular health plan, covers abortions.[22] As a result, “exceptions” are exercised rarely. In 2010, the 34 states (including the District of Columbia) that adhere to the Hyde restrictions contributed to the cost of only seven abortion procedures; the federal government contributed to the cost of just 331 procedures. The 17 states that use their own funds to pay for most or all medically necessary abortions provided to Medicaid recipients covered about 181,000 abortions.[20]

Furthermore, these restrictions communicate loaded, destructive messages regarding women’s worth, sexuality, autonomy, and competence. One such message is that women are entitled to terminate a pregnancy only if they can establish that it resulted from circumstances beyond their control (rape) and/or a situation more morally reprehensible than their own customary behavior (incest).

The exceptions may also imply that funding for abortions in other circumstances is unwarranted, and therefore they unfairly target and discriminate against disenfranchised groups, particularly women of color, young women, and women in poverty. Such women are more likely to access vital reproductive health services through the public health system and lack funds to cover out-of-pocket expenses for safe abortion care outside of the recognized exceptions.

Other coverage and funding restrictions (federal, state, private sector): In the United States, most commercial insurance plans have routinely covered abortions. The Patient Protection and Affordable Care Act (ACA) has created new state insurance marketplace exchanges that offer “private” affordable commercial health insurance with federal subsidies to help pay the premiums. The ACA restricts women’s ability to obtain coverage that includes abortion services.[21]

Twenty-five states restrict abortion coverage to limited circumstances in insurance plans created through the ACA. Ten states restrict the circumstances under which any private insurance will cover abortions.

In states that allow abortion coverage to be offered through their state insurance exchanges, the ACA requires consumers to make two premium payments: one for abortion coverage and one for every other covered benefit. Insurers are required to process those two payments from the individual and a third payment from the federal government for any subsidies to which the enrollee is entitled, in order to segregate the federal subsidy money from the insurer’s private abortion premium payment.

These developments establish a questionable standard regarding the nature of “public” and “private” sources of payment for health care services and use of payment source as a basis for determining health policy. Domestically, this has contributed to destabilizing the basis for group insurance coverage, an important aspect of health policy. Group insurance is built in part on the principle that the risk of financial loss for unforeseeable events, such as a health condition, can be reduced by combining a “sufficient number of exposure units to make their individual losses collectively predictable. The predictable loss is shared proportionately among all participants. The risk is reduced or eliminated for the insured, and all the individuals who paid into the fund share the resulting loss.”[23]

Authorizing individual employers and individuals to withhold paying for insurance coverage for selected benefits that they do not want or of which they do not approve, for virtually any reason, undermines this system. The Supreme Court’s decision in 2014 in the Hobby Lobby case on contraception coverage in private health insurance plans asserts that an insurance purchaser’s religious beliefs about a medical procedure or benefit, if sincerely held, are a higher standard for determining the responsibility to contribute to group insurance coverage for that procedure or benefit than scientific and medical evidence or the preferences or experiences of the covered group as a whole. While the immediate procedure at issue was a contraceptive erroneously believed to be an abortifacient, the decision undermines the basis for group funding for any health insurance purpose, and arguably for any government purpose, while also undermining the validity of scientific evidence as a basis for public health policy.[24]

In summary, restrictions on coverage and funding for abortions undermine sound health policy, present significant risks to women’s health and rights, and disproportionately threaten the health and life chances of underserved communities by (1) codifying the government’s right to provide a lower standard of health care coverage based on gender and income and treating funding for abortions for low-income women differently, even though abortion is a legal health care service; (2) treating abortion differently from other health care services, thereby stigmatizing it; and (3) fragmenting women’s interests in and experiences of access to abortion by income and by characteristics associated with income, including race/ethnicity, level of education, and geographic location.

Increasingly onerous obstruction of women’s access to abortion services in addition to funding and coverage: A variety of restrictive measures aim to discourage or delay women from obtaining an abortion, although abortion is least challenging at the earliest stages of pregnancy.[25] These restrictions include the following:

  • Restrictions on provision of medication abortion, such as overriding management via telemedicine[26]
  • Gestational age limits for abortion set at between 6 weeks and 20 weeks from fertilization
  • Parental consent required before a minor obtains an abortion
  • Mandatory counseling prior to abortion
  • Mandatory waiting periods between time of first appointment and abortion
  • Requirement to have an ultrasound prior to an abortion
  • Requirement (in five states) to inform women that abortion causes breast cancer, although it does not[27]

Targeted regulation of abortion providers (TRAP) laws obstruct providers’ ability to practice by imposing requirements beyond what is needed to ensure patient safety, creating huge barriers to access. These barriers include:

  • Requiring licensed physicians to perform abortions. This excludes qualified clinicians, such as nurse practitioners, who can safely perform abortions[28,29] and denies access to women in rural areas where physicians are not available.
  • Imposing ambulatory surgical center standards on facilities providing abortion, such as specified room sizes.
  • Requiring abortion providers to obtain hospital admitting privileges. This requirement does not contribute to patient protection or safety. Abortions are safely performed outside of hospitals. In the rare event of post-abortion complications, existing emergency department staff can provide necessary care.[30] However, the requirement does grant hospitals effective veto power over whether an abortion provider can practice, including the one in six US hospitals that are Catholic owned or supported and that, as a group, oppose the provision of abortion services.

In addition, individual clinicians can elect to refuse to provide abortion services.

TRAP laws have already forced numerous clinics to close, including almost all abortion providers in Texas. The regional clustering of restrictions in the South and Midwest makes it difficult for many women to obtain needed abortion care within a reasonable distance from their homes.

Impact of attacks on abortion care on discrimination: Social determinants of health begin with pregnancy, according to Marmot et al. “The interaction between gender inequities and other social determinants increases women’s vulnerability and exposure to risk of negative sexual and reproductive health outcomes. Poor maternal health, inadequate access to contraception, and gender-based violence are indicators of these inequities.”[31]

The overall rate of abortions is declining in the United States as contraceptives become increasingly widespread and effective.[32] However, while 40% of pregnancies are unintended worldwide, the US rate is higher, at 51%.[33]

Unintended pregnancies are increasing among low-income women and women of color and declining among women with incomes above 200% of the federal poverty rate and White women.[34] Rates of unintended pregnancy and unintended birth among women of color are more than twice the rates for White women. Black women have the highest unintended pregnancy rate, while Hispanics have the highest rate of unintended births.[35,36]

Poor women are five times as likely as higher income women to have an unintended pregnancy, five times as likely to have an abortion, and six times as likely to have an unplanned birth.[37] Medicaid coverage of abortion has an important effect on the ability of poor women to end unintended pregnancies.[38] About one in four women who would have had Medicaid-funded abortions instead give birth when this funding is unavailable.[39]

Low-income women who are able to raise the money for an abortion have reported that they often do so at a great sacrifice to themselves and their families, diverting money that would otherwise be used to pay for rent, utility bills, food, and clothing for themselves and their children. In addition, costs and the risk of complications increase with increasing gestational age.[40]

Impact of abortion restrictions on women’s incomes and income inequality: Policies that deny women abortions they seek deepen and entrench poverty among women and children. The Turnaway Study showed that women denied abortions were three times as likely to end up below the federal poverty line 2 years later as similar women who sought and obtained an abortion.[13]

Discrimination based on gender, race, and other social characteristics undermines economic opportunity and growth. Freeing the productive talents of the population benefits economic growth, particularly in economies dependent on consumer purchases.[41] Abortion restrictions weaken women’s personal economic status and their potential contributions to the economy. Income inequality persists and is widening, drawing concern from the US president[42] and the Pope.[43]

Association between anti-abortion measures and population health: States with more anti-abortion policies have significantly lower indicators of infant/child well-being.[44] Women in states that prohibit Medicaid funding of abortions have significantly higher rates of postpartum depression than women in states that fund Medicaid abortions.[45]

A recent major report by the Center for Reproductive Rights and researchers at Ibis Reproductive Health[46] evaluated the association between enactment of anti-abortion policies and passage of state policies known to improve the health and well-being of women and children or to improve state-level health outcomes in these groups. They also examined health policies and women’s and children’s outcomes in states with relatively few abortion restrictions.

The report evaluated the prevalence of 14 state abortion restrictions against indicators of population health in four topic areas: women’s health outcomes, children’s health outcomes, social determinants of health, and policies supportive of women’s and children’s health. The authors found an inverse relationship between a state’s number of abortion restrictions and its number of evidence-based policies supporting women’s and children’s well-being. States with more abortion restrictions tend to have fewer supportive policies in place, policies that are crucial to ensuring that women and families are able to live healthy and safe lives.

The authors also found that the more abortion restrictions that were present, the worse a state performed overall on indicators of women’s and children’s well-being. Among the 23 states with 0–6 abortion restrictions, 18 (78%) were above the median overall well-being score. In contrast, only 8 of the 28 states with 7–14 abortion restrictions (29%) were above the median.

Debate on abortion has polarized Congress and many state legislatures , undermining their ability to address other pressing policy concerns.

Evidence-Based Strategies

The public health community must explore strategies to intervene quickly and effectively, including the following:

  • Eliminate restrictions on funding and coverage for abortions.
  • Restore public funding for abortions by reversing the Hyde and Helms amendments.
  • Reverse all policies, in addition to funding and coverage restrictions, that impede access to abortions owing to their negative public health consequences.
  • Assert that severe barriers to access for abortions violate women’s right to bodily autonomy, constituting cruel, inhuman, or degrading treatment. Denying abortion rights violates women’s autonomy. Substantial evidence asserts disproportionate effects of abortion restrictions on women on the basis of race, income, and gender. Human rights bodies are increasingly finding that denying or obstructing a woman’s access to abortion can amount to “cruel, inhuman, or degrading treatment…under multiple human rights treaties,” that “the State’s failure to act to prevent de facto restrictions [is] unjustifiable and disproportionate to lawful State aims,” and that “deprivations of autonomy in reproductive rights context[s] can lead to the kind of pain and suffering that is unacceptable in modern societies.”[11]
  • Investigate and implement strategies that reverse stigma associated with abortion care services. Funding bans and other barriers stigmatize and isolate women who need abortions (including stigmatization and isolation according to income and race/ethnicity) and also stigmatize providers.
    • Women who seek and undergo abortions: Public health campaigns focusing on reproductive health should build support for women who undergo abortions. There should be solidarity with and respect and empathy for people stigmatized as “other,” and the right to equal treatment should be asserted. Also, parallel lessons from successful campaigns promoting access to contraception in Ireland and marriage equality in the United States should be explored.
    • Providers of abortion care services: Conscientious provision of abortions should be recognized and promoted, with affirmative and public assertion of the value of abortion care. Such care should be framed as an extension of health care clinicians’ requirement to place patients’ needs as the highest priority in providing treatment.[47]

Public health agencies, health plans, and other health care providers and institutions serve the public’s health and interests when they affirmatively state and publicize the range of reproductive health care services they perform, provide, pay for, and otherwise make available.

According to one authority, “The exercise of conscience in health care is generally considered synonymous with refusal to participate in contested medical services, especially abortion. This depiction neglects the fact that the provision of abortion care is also conscience-based. The persistent failure to recognize abortion provision as ‘conscientious’ has resulted in laws that do not protect caregivers who are compelled by conscience to provide abortion services, contributes to the ongoing stigmatization of abortion providers, and leaves theoretical and practical blind spots in bioethics with respect to positive claims of conscience—that is, conscience-based claims for offering care, rather than for refusing to provide it.”[48]

Public health has an important responsibility to destigmatize abortion care and legitimate the public health benefits of abortion care and rights.

Opposing Arguments

One opposing argument focuses on the safety of abortion. However, abortion is one of the most common and safest surgical gynecological procedures. In the United States, about 1.2 million abortions are performed each year, representing approximately 18% of all pregnancies.[49] By the age of 45 years, approximately one third of US women will have had an abortion.[2] The risk of death from carrying a pregnancy to term is 14 times higher than that of abortion in the United States.[49]

Some opposition groups have attempted to assert that abortions harm women’s health. In a five-part response to preliminary findings of the Turnaway Study, National Right to Life asserted that abortion is associated with conditions including breast cancer, future miscarriage, infertility, and mental illness, although these conditions may become apparent only later. Reputable research does not support such claims. There is no association between abortion and breast cancer.[27] In addition, the Turnaway Study and others showed “no correlation between having an abortion and increased symptoms of depression and anxiety.”[13,50]

Some opponents of public funding for abortion assert that although abortion is legal, denial of public funding is a fair concession to the interests of those who object strongly to abortion on moral or religious grounds and prefer not to contribute financially to this practice. Noted philosopher and ethicist David DeGrazia, for example, presents this argument in his book Creation Ethics. Refuting this view, Sheelagh McGuinness argues that such a policy makes abortion available to those who can afford it and inaccessible to those who cannot.[51] The policy therefore overlooks concerns for equality and social justice. According to McGuinness, “DeGrazia privileges a minority view in how public funds are allocated…rather than the rights of women as equal citizens. DeGrazia’s position means that the well-being of those with less wealth is being sacrificed in order to ease the feelings of those who [oppose the legality of abortion.] This model…fails to take a woman’s interest in controlling her body as a starting point for shaping a policy that places restrictions on her ability to act in certain ways. Poor women are being denied their agency and the right to construct themselves as full citizens.” DeGrazia highlights the failure of reproductive liberty arguments to take seriously the interests and needs of women, allowing for a system wherein abortion is permissible but difficult to access. As DeGrazia states, while the status of the fetus is metaphysically uncertain, the status of women is not. And the reality of lack of access to abortion care is a hard social fact. We should therefore “err on the side of what is most likely and ensure that women have real access to safe and legal care.”

Most religious organizations in the United States support reproductive rights and access to safe, legal abortions.[52] However, some conservative religious groups disagree that preventing unintended pregnancies is a public health goal. Some Christian evangelicals, and some sectors of the Catholic Church such as the US Conference of Catholic Bishops, assert that conception is a divine occurrence, with which individual humans cannot interfere. Some further argue that it is women’s responsibility to accept that heterosexual activity may result in a pregnancy. Once pregnant, a woman’s own health, economic prospects, and self-determination are secondary to her responsibility to see the delivery to term.

These groups oppose efforts to modify the traditional biologically and religiously assigned roles of men and women.[53]

Given the discriminatory nature of these beliefs and assertions, opponents of abortion rights have frequently expressed their beliefs in appeals to more mainstream American values, such as the right to free speech and the right to direct the expenditure of certain public and private funds. As documented here, these incursions into women’s rights have devastating effects on their lives and on democracy.

The Montana Supreme Court applied strict scrutiny in considering a physician-only abortion restriction. The state had to demonstrate a compelling state interest for infringing on a woman’s right in “making personal health care decisions and in exercising personal autonomy.” The court found that the state’s only possible compelling interest that might override the right to personal autonomy in making health decisions was that of “regulat[ing] or preserv[ing] the safety, health and welfare of…patients or the general public from a medically-acknowledged bona fide health risk.” The court deemed that legislating “under the guise of protecting the patient’s health,” but in reality in the interests of political ideology or personal beliefs or values, was “not only constitutionally impermissible [but] intellectually and morally indefensible.”[29]

Action Steps

  • APHA calls on members, components, and elected officials to work to eliminate restrictions on public funding for abortions, including the Helms and Hyde amendments, and advocate for states to both expand income eligibility for their Medicaid programs and cover abortions through Medicaid.
  • APHA calls on health care clinicians, institutions, and health plans to practice “conscientious provision” of abortion: to affirmatively and publicly assert the value of abortion care and to frame such care as an extension of the commitment to place the needs of patients as the highest priority in providing services. This includes the obligation to refer patients for reproductive health care services not available through particular providers.
  • Public health as a community—individuals, workers, professionals, academics, organizations, and officials—must identify and overcome the impact of stigma on suppressing public discussion, debate, and action on abortion; recognize the disproportionate impact of abortion stigma on less powerful populations, particularly low-income women, young women, and women of color, and on population health; and engage peers, communities, and policymakers in supporting universal access to accurate, evidence-based information about comprehensive sexual and reproductive health inclusive of safe abortion care, as well as access to a full range of safe, legal, and affordable sexual and reproductive health services.
  • There is a need to advance communications with policymakers and religious leaders regarding the effects of abortion stigma on economic inequality. Also, APHA calls on these leaders to forge a 21st-century policy on women’s rights and on abortion as a key reproductive health care service.[54]
  • APHA calls on the public health profession as a whole, as represented by its professional organizations, to become actively involved in these activities.

References

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2. American Public Health Association. Policy No. 20103. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/10/48/protecting-abortion-coverage-in-health-reform. Accessed December 28, 2015.  

3. American Public Health Association. Policy No. 20003. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/29/08/13/preserving-consumer-choice-in-an-era-of-religious-secular-health-industry-mergers-position-paper. Accessed December 28, 2015.

4. American Public Health Association. Policy No. 200314. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/15/12/support-for-sexual-and-reproductive-health-and-rights-in-the-united-states-and-abroad. Accessed December 28, 2015.

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6. American Public Health Association. Policy No. 20112. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/28/16/00/provision-of-abortion-care-by-advanced-practice-nurses-and-physician-assistants. Accessed December 28, 2015.

7. American Public Health Association. Policy No. 201113. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/24/10/10/call-to-action-to-reduce-global-maternal-neonatal-and-child-morbidity-and-mortality. Accessed December 28, 2015.

8. Dehlendorf C, Harris LH, Weitz TA. Disparities in abortion rates: a public health approach. Am J Public Health 2013;103:1772–1779.

9. SisterSong. Why is reproductive justice important for women of color? Available at: http://sistersong.net/index.php?option=com_content&view=article&id=141. Accessed December 28, 2015.

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